BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHD PARTMENT &STERFILE RECORD INFORMATION FA SHADED SECTIONS FOREHD USE ONLY OWNER ID 111 1 6000 a�p&59 II CASE# OWNER FILE COMPLETE THEFOLLOwING BUSINESS OWNER INFORMAT/ON: CHECK IF OWNER CURRENrc YON FILE wiTH EH D❑ BUSINESS OWNER'S NAME !v1 PMI _ /� 'e l PHONE: First fast BUSINESS NAME (If different tram Owner Name) III 01,11-S L( G Soo Seo orTax ID # OWNER'S HOME ADDRESS CITY STATE ZIP OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of MAILING ADDRESS CITY (S -!S- �v e_ S+- ,�� ST TE ZIP t Dia TYPE OF OWNERSHIP: CORPORATION ❑ INDIVIDUAL ❑ PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY ❑ STATE AGENCY ❑ FED AGENCY OTHER ❑ FACILITY FILE FACILITYID#:}�,U2if�t� Co-OWNERID#: AccoUNTID#:,pOL%I}C COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: NEW BUBlness LOCATION Or VEHICLE not preVlOusly regulated by the ENVIRONMENTAL HEALTH YES ❑ NO..v.,rI Fthis n EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ❑ BUSINESS/FACILITY NAME (This will be the BUSINESS NAII the HEALTH PERMIT) GVta,:IS FACILITY ADDRESS (H FAC/L/TYI6 a MOSILEF600 UNITor FOOD VEHICLEusa the COMMISSARY ADDRESS) BUSINESS PHONE (?-2-10 5. A&I o, el //y suite# -561- CITY (if FACILITYIs a MOBILE FOOD UNI FOOD VEHICLE use the COMMISSARY CIN) STATE ZIP (I(^EZ� YI c G. 4 CA BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health PerMit(If DIFFERENTfrom Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: COMMENT: ACCOUNTADDRESS for fees and charges: OWNER ❑ FACIUTYIBUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated With this operation will be billed to me at the address identified above as the ACCOUNT ADDRESS for this site. I also certify that all information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or SIGNATURE: Please Print TITLE: GATE DRIVER'S LICENSE Approved By I Date II Accounting Office Processing Completed By 11146 I Dete -7/I D A PROGRAM (EHD 48412-034 Pink) or WATER SYSTEM (EHD 46-02-003) form must be completed for each EHD regulated operation at this LOCATION except UST Program (Use SWRCB forms) EHD 48-02-035 Masterfile Record -Green 8H9/08